UKMLA/PLAB Style Question Analysis: Management of Hypokalemia in a Patient with Cirrhosis
Understanding Key Clinical Scenarios for UKMLA and PLAB Success
In this article, we explore a high-yield concept, highlighting the essential principles of managing hypokalemia in a cirrhotic patient on diuretic therapy. This type of scenario is frequently encountered in medical licensing exams such as the UKMLA, PLAB, and USMLE. It tests the candidate's ability to prioritise clinical issues while managing complex chronic conditions like cirrhosis.
PLAB Exam Style Case Scenario: A 65-year-old man with a known history of cirrhosis presents to his GP with increasing abdominal distension and swollen ankles. He has been on furosemide 40mg once daily for the past 2 weeks.
On examination, he has marked ascites and pitting oedema up to his knees.
Blood tests show:
Serum albumin: 28 g/L (35-50)
Serum potassium: 3.2 mmol/L (3.5-5.0)
Which is the most appropriate next step in management?
A) Increase the dose of furosemide to 80mg once daily
B) Arrange an urgent diagnostic ascitic tap
C) Prescribe oral potassium chloride supplements
D) Refer for consideration of liver transplantation
E) Commence an intravenous infusion of human albumin solution
Answer with an explanation is provided below
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Explanation to the above August 2024 PLAB exam question
Correct Answer: C) Prescribe oral potassium chloride supplements.
Rationale and Explanation
Key Considerations in the Clinical Scenario
Hypokalemia and Its Risks:
The patient’s potassium level is significantly below normal, placing them at risk of complications such as arrhythmias, muscle weakness, and exacerbation of hepatic encephalopathy.
Cirrhosis and Diuretic Therapy:
Furosemide, a loop diuretic, is effective in managing ascites but can lead to electrolyte imbalances such as hypokalemia. Addressing the hypokalemia is critical to continue diuretic therapy safely.
Immediate Priority:
The hypokalemia must be corrected promptly to stabilise the patient and prevent life-threatening complications.
Why Oral Potassium Chloride Supplements Are the Best Next Step
Correction of Hypokalemia: Oral potassium chloride is the first-line treatment for mild to moderate hypokalemia, effectively replenishing potassium levels.
Prevention of Further Complications: Correcting potassium levels ensures that the patient can continue diuretic therapy safely, avoiding exacerbation of ascites and oedema.
Non-Invasive and Efficient: Oral supplementation is less invasive compared to intravenous correction, which is reserved for severe hypokalemia.
Why Other Options Are Less Appropriate
A) Increase the Dose of Furosemide to 80 mg Once Daily:
Escalating the dose without addressing hypokalemia could worsen the potassium deficit, increasing the risk of complications.
B) Arrange an Urgent Diagnostic Ascitic Tap:
Although an ascitic tap is indicated if spontaneous bacterial peritonitis (SBP) is suspected, there is no evidence of infection (e.g., fever, abdominal pain). The immediate priority is correcting the hypokalemia.
D) Refer for Consideration of Liver Transplantation:
Referral for transplantation is a long-term consideration for cirrhosis but does not address the immediate concern of hypokalemia.
E) Commence an Intravenous Infusion of Human Albumin Solution:
Albumin infusion is indicated for specific situations like large-volume paracentesis or severe hypoalbuminemia causing circulatory dysfunction. Here, the low potassium level is the priority.
Management and Follow-Up
Immediate Actions:
Start Oral Potassium Supplements:
Prescribe potassium chloride to correct the hypokalemia.
Monitor Electrolytes:
Reassess serum potassium after supplementation. Ongoing monitoring is essential in patients on diuretics.
Adjust Diuretic Therapy:
Consider adding a potassium-sparing diuretic like spironolactone, which can help manage ascites while minimising potassium loss.
Address the Underlying Cirrhosis:
Monitor for potential complications of cirrhosis, such as SBP or hepatorenal syndrome.
Evaluate the need for referral to a specialist for advanced therapies or liver transplantation.
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Reference:
NICE Guidelines: Urinary Tract Infection in Children and Young People.
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